DDN February 2022 February 2022 | Page 10



In the second of a threepart series , Dr Georges Petitjean and Deanne Burch explore different buprenorphine preparations , its use during the COVID-19 pandemic and its safety and cost in comparison to methadone .

Different forms of buprenorphine have been developed since its introduction into the drug and alcohol field as an alternative to methadone . Transdermal patches were launched in Germany and Switzerland in 2001 for analgesia , and buprenorphine / naloxone sublingual tablets ( also known under the brand Suboxone ) were authorised for marketing in 2017 in Europe . The buprenorphine contained within buprenorphine / naloxone is absorbed sublingually but the naloxone component has a 5-10 per cent absorption , essentially leading to a low clinical effect . However , if the buprenorphine / naloxone is injected this would enable a dose of naloxone to induce opioid withdrawal , providing a reduced potential for misuse .

ADVANTAGE In 2017 buprenorphine lyophilisate ( also known under the brand Espranor ) was introduced to the UK market . Buprenorphine lyophilisate had the advantage of dissolving on the tongue , enabling quicker supervision by pharmacists and making diversion less likely . Many drug treatment services switched to prescribing buprenorphine lyophilisate amid the increasing cost of sublingual buprenorphine in an effort to manage budgets . The increased bioavailability of buprenorphine lyophilisate presented an initial challenge for drug treatment services who wished to switch patients from sublingual buprenorphine , as the products were not believed to be dose interchangeable .
METHADONE DOMINATION Despite there being good evidence that buprenorphine is as effective as methadone as a form of opiate substitution treatment ( OST ) for maintenance and detoxification , and its perceived safety , rates of methadone prescribing continue to dominate those of buprenorphine within UK drug treatment services . In regards to its safety , buprenorphine – like methadone – can cause respiratory depression leading to death , but this is more common when buprenorphine is used in conjunction with other sedatives such as alcohol or benzodiazepines .
During the early months of the COVID-19 pandemic drug services closed to minimise the


We asked several experts about their views on the differences in cost , the uptake of buprenorphine lyophilisate within treatment services , and the role of the commissioner in supporting the cost-effectiveness of treatment .
What were the differences in cost that presented challenges for drug and alcohol services ?
Linda Geddes , lead pharmacist for Inclusion : Around 2019 there was a significant increase in the drug tariff costs for buprenorphine of up to 800 per cent , while methadone costs remained relatively stable . During the same period a number of services saw a reduction in funding received from commissioners . Affected services needed to review their service model in order to continue to serve the population effectively and give service users a choice on the pharmacological treatment offered . The alternative would have been to employ strict rules on buprenorphine prescribing pathways such as time-limited treatment , having the drug as a second choice on formularies – restricting service user choice – and having stricter rules on testing for illicit substance use .
One solution adopted by a number of services was to
implement a buprenorphine pharmaceutical rebate scheme , the application of which did not influence prescribing as the therapeutic intervention already had a place in clinical practice . This provided stability in the cost of the drug , allowing services to manage drug budgets as well as providing significant efficiency savings that could be re-invested into the service . Whilst it is acknowledged that these rebate schemes could undermine the competition required to drive down the costs of medicines , a number of service providers felt compelled to sign up to these schemes in order to remain viable .
Primary care rebate schemes are now a common feature within the UK health system , with a significant number of schemes in operation . PrescQipp ( a not-forprofit community interest company set up to help NHS organisations to improve medicines-related care to patients ) have created the Pharmaceutical Industry Scheme
Governance Review Body ( PISGRB ) with the sole aim of giving an unbiased view on the available rebate schemes and making a recommendation to commissioners as to whether these schemes can be supported .
Are you able to give us an indication of the estimated savings achieved by drug and alcohol providers following the switch from generic buprenorphine / Subutex to Espranor ?
Paul Concannon , senior vice president of commercial operations at Ethypharm : We estimate that since the start of 2019 we have saved the NHS approximately £ 14,760,000 across all the UK services that have offered Espranor when compared to the generic drug tariff over that period .